Bones are organs.
While we often think of bone as this inert or static structure, bones are just like the heart, lungs or liver and are alive.
And it’s easy to take out bones for granted, especially when we are younger.
Part of this is because so much of the talk about bone issues, like osteoporosis or hip fractures, feels directed at the elderly.
For example, it’s well established that for those who are older (50 and over but it’s particularly true for those 65 and above), they’re significantly more likely to die within a year of having a hip fracture. And this increased risk for premature death can carry on for several years after the fracture.
And what are the causes of death connected to this? How can a hip fracture lead to death? According to this paper, “Among hip surgery patients, the most common causes of death were circulatory diseases, followed by dementia and Alzheimer’s disease.”
It also states that “Excess mortality after hip fracture may be linked to complications following the fracture, such as pulmonary embolism, infections, and heart failure.”
So, you may be asking yourself: Why do I care about what happens to those in their 60s or above? I’m decades from hitting that point. This is something that happens to “old people” and that’s not me.
As someone who spends my days working with eating disorders, particularly restrictive eating disorders like anorexia, the issue of bone health is something that comes up a lot.
But even when someone receives a diagnosis of osteoporosis in their 20s or 30s there can be a misunderstanding of what this really means and the potential long-term issues that this can cause.
So today on the blog, I’m going to cover why bone health is crucially important, irrespective of your age. And how bone health is connected to the wider health of the body and in a sense, can be a proxy for how other systems are working.
(Note: Part of my inspiration for writing this post, outside of the fact that this is a common problem that clients face, is Dr Jennifer Guadiani’s excellent book Sick Enough. In it, she has a whole section on bone health and there was much that was new information to me.
We covered some of it when I had her on the podcast, which you can listen to here. But there is much we didn’t cover, hence this post).
It’s helpful to start by looking at the functions of bones because they are more than simply the coat rack that holds up your meat suit.
In addition to supporting the body’s structure by allowing the muscle to attach to the bones, bones help us to move. They also protect the internal organs.
Bones are also the production site for many of your blood cells. These include:
Bones are also one of the major sites where defective or aged red blood cells are destroyed. The body is constantly in a state of anabolism (building up) and catabolism (breaking down) and so getting rid of old cells is incredibly important.
Bones act as a depot, where they can both store and release substances. Some of these substances include:
Bones also function as endocrine organs, meaning they release hormones. For example, they release osteocalcin, a hormone that has an impact on blood sugar regulation and fat storage.
As you can see, bones have many functions and are connected to many systems of the body. And if they are not working as they should be, issues can easily occur in seemingly unconnected systems. Whether we’re talking about anaemia, hypothyroidism, or repeated urinary tract infections, bone health can be playing a role.
I mentioned earlier that bones are living organs. This means that they are constantly being broken down and recreated.
In a healthy human being, up until the age of about 30 or 35 our bone growth will be higher than that of our bone breakdown. And there will obviously be points, like in puberty and certain times in childhood, when this bone growth will far exceed our bone breakdown.
Our peak bone density is around our late 20s and early 30s. From about 35 through to age 50, bone breakdown and build-up are roughly equal, with a little more breakdown. Then in our 50s, bone breakdown increases and outstrips the rebuilding and this happens more quickly in women than it does in men.
So what is driving these processes?
Calories are one important part because the body needs energy for this process. Without sufficient calories, bone growth in particular will be impeded.
Hormones are another part. There are hormones like growth hormone, cortisol and insulin-like growth factor (IGF-1). And then there are the so-called “reproductive hormones,” which do a lot more than reproduction. For women this is oestrogen and progesterone and for men testosterone.
And it’s these reproductive hormones that are responsible for the times of more drastic bone building and bone reduction. During puberty, these hormones are produced in high amounts and during menopause, these hormones are falling away in drastic amounts.
Even men, who may not have an official menopause, will see the levels of testosterone decline as they age, just not as sharply as in women. And hence, men will also see a decline in bone health as they age too.
When assessing bone health, two markers are used: Bone Mineral Density (BMD) and Bone Mineral Content (BMC).
Essentially, these markers measure how much calcium and other types of minerals (like carbonate, magnesium, sodium, and potassium) are in an area of bone.
While there are many methods for measuring the content and density of bone, the most common is Dual-energy X-ray absorptiometry (abbreviated to DEXA or DXA).
The DEXA test scans the body and measures specific bone or bones, usually the spine, hip, and wrist. Based on this scan you receive two types of results:
For those under the age of 50, the Z-score is the marker used. There are three results you can receive:
A “secondary cause of osteoporosis” as Dr Gaudiani talks about is “either a low testosterone score or erectile dysfunction in a male, or absent or irregular periods or low oestradiol levels in a female.” What causes these lower hormone levels? One common reason is disordered eating or an eating disorder.
I should also mention that while normal bone density is referred to as above -2.0, the real aim should be zero or above. At zero you are equal to what would be expected of others who are your age, sex and ethnicity. It really is a confusing scoring system.
For those over the age of 50, the T-score is the marker used. Again, there are three results you can receive:
(Note: As you can see above, for those over 50 there is an option of “osteopenia” while for those under 50 it’s called “below the expected range for age”.)
Now, it can be easy to look at these numbers and for it to feel cold or detached from what is being measured. “So what if my T-score is -2.2, that doesn’t seem so bad?”
A big part of this is because when we think about weak bones and hear about “fracture risk” we often think “well that’s not going to happen to me.” You may understand that if you trip over, you’re more likely to break your wrist, so you think “I’ll just be careful and not trip over.”
But the reality is no one intends to trip over. And while a broken wrist is obviously no fun, it’s something that can be put in a cast and the arm is relatively easy to cease or limit using. Healing time will be much slower with low bone density and insufficient energy coming in to help with repair, but life can continue with a wrist in a cast.
But there are two other areas that I want to mention that aren’t so simple.
The first is compression fractures of the vertebrae. When the vertebrae become weak and fragile, they can lose height and collapse down. This may lead to pain, deformity, loss of height and the crowding of internal organs.
Without surgery, this is permanent. And even with surgery, the outcome isn’t great. It doesn’t reverse the damage but merely fuses the two vertebrae together to eliminate the motion to try and reduce the pain.
When compression fractures occur, rarely are they even, most often they crunch forward, so that the spine is hunched forward, known as kyphosis. As Dr Gaudiani states “No amount of posture work or yoga can fully fix this curvature once the bone is altered.”
Another issue is stress fractures and this is very common with the clients I see. A stress fracture is a small crack in the bone. These are regularly seen in the feet, ankles and lower legs and are much more likely with repetitive activity.
Unlike a broken wrist, because stress fractures are typically in the feet, legs and hip it’s much more difficult to carry on with your regular day-to-day with a fracture in these areas.
And even though this is a “small crack” it can take months to heal. Often, it is longer than this, because someone feels unable to take the time off exercise. They are also unable to provide the body with the energy it needs to make the repairs.
When the body is receiving less than it needs, certain functions have to be turned down or shut off. And this is true for bones.
This is because restriction has an impact on the two factors I previously mentioned: sufficient calories and hormone production. When less energy is coming in the hormones that promote bone growth are turned down or completely shut off.
I think it would be useful to look at how this plays out for different areas of life and different groups.
Growth doesn’t happen at a steady rate. From the moment a child is born right up until puberty, there will be times of slower growth punctuated by mini growth spurts. (Fun fact: kids tend to grow faster in the spring and summer time compared to the autumn and winter).
But puberty is probably the point of life where, for a fairly short amount of time of roughly three years, the body experiences massive amounts of growth. If restriction is happening leading up to or during puberty, it affects this growth.
At the extreme end, it can halt puberty completely, but further along the continuum, it will slow growth.
Unfortunately, when we are focusing on bones, this is a window of time that you don’t get back. Insufficient energy during puberty means bones will never reach what could have been their full potential.
This affects the full height that is reached, leading to a shorter stature.
But it also affects the maximal bone density that occurs, and from age 30 when this starts slowly declining for all of us, the high point is less than where it could have been.
If we look at women who have reached and passed puberty, restriction can continue to affect bones.
As I mentioned earlier, bone growth is intimately tied to reproduction, because the so-called reproductive hormones are also needed for bone growth. This means that bone growth is often thought about in women only when menstruation stops.
Regularly, I work with clients who are taking the oral contraceptive pill because they are missing their period. They have been advised that, for the sake of their bone growth, the pill should be taken.
But despite this being widely recommended, this is incorrect advice. To quote Dr Gaudiani “oral contraceptive pills neither protect bone nor “jump start” the period.” What does support bone growth is ending restriction and having the body turn back on the reproductive processes.
Now I should add, as I talk about in this article, that just because a period is happening, does not mean that everything is working optimally. There are still often lots of repairs that still need to happen after a period has resumed. But getting a period to return if it has stopped is the first priority in support of bone health.
If we now turn our attention to men, a similar situation can happen, even if it’s not so obvious.
Men don’t have a ceased period as an obvious marker but there still can be symptoms: decreased interest or desire for sex, no longer waking with a morning erection or experiencing erections through the night. These changes are largely connected to a decrease in testosterone.
And just like in women, the lack of this hormone affects bone growth and density.
There is a condition called serous bone marrow atrophy or gelatinous bone marrow transformation (GMT for short). It can occur when there is a serious illness alongside poor nutritional status and weight loss. So, conditions like AIDS, cancer and congestive heart failure, as well as anorexia (connected to the restriction and malnourished state).
While it is a fairly rare condition, it affects men more than women, with this paper putting it at a rate of 2:1. It was actually one of my male clients who was diagnosed with it and brought it to my attention.
Serous bone marrow atrophy leads to the reduction in bone marrow (as the name suggests). When I mentioned earlier that bone is used to produce red blood cells, white blood cells and platelets, this is the job of the bone marrow. This means that serous bone marrow atrophy is often accompanied by anaemia.
There are several reasons that I’m mentioning this.
One, this isn’t diagnosed via a DEXA scan. Typically, it is diagnosed using an MRI, but depending on the location may require a biopsy.
Two, its appearance on an MRI is somewhat odd. This can mean if someone isn’t aware of serous bone marrow atrophy there can be repeated MRIs done, thinking that there is a technical issue with the machine.
Three, it can lead to insufficiency fractures, which are a type of stress fracture. I mentioned earlier that stress fractures often occur in the feet, ankles and lower legs, which is also true of insufficiency fractures. But they can also occur in areas of your body that carry a lot of your weight; specifically, the pelvis, spine, and hips. Areas you really do not want to be fracturing.
And these fractures don’t take an obvious fall to occur. The bone is so fragile that bumping or knocking into something can be enough to cause a fracture.
And finally, again because of how serous bone marrow atrophy affects the MRI, it means that these fractures can be difficult to see and can easily be missed. So while you are complaining of constant pain in the hip or spine, an MRI can be done and you are told that nothing is showing up, when in fact a fracture has occurred.
There is another group that I think is worth mentioning, which is athletes. And like I mentioned in this article about Relative Energy Deficiency in Sport (RED-S), the word athlete needs to be defined more broadly than just professional athletes. This is really about anyone who is training regularly, with the higher the training load, the more it will apply.
Several things can increase bone density outside of just adequate calories, nutrition and hormones. Exercise is one of them and athletes can have 5-20% higher bone density because of adaptions the body makes connected to the force of movement.
I talked earlier about the T-score or Z-score as a measure of bone density and fracture risk. What’s important to understand is that a DEXA scan and the resulting score is a snapshot of where the bone is right now and doesn’t tell you anything about the actual bone turnover.
It is also comparing you to others who are the same age, sex and ethnicity but isn’t necessarily factoring in the effects of the above-average exercise for someone who is an athlete.
So why is this important?
Let’s imagine that there is an athlete and a non-athlete. They were both healthy individuals but then in their 20s developed an eating disorder. This has now been going on for the last five years and they are suggested to get a DEXA scan to check their bone health.
The non-athlete receives a Z-score of -2.2 and the athlete receives a Z-score of -1.5. On paper, the non-athlete appears much worse off and it looks like the preceding five years have done more damage to their bones. The non-athlete would likely be diagnosed with osteoporosis while the athlete would be told they are fine.
But if we go back five years earlier, before the eating disorder began, we could see that they were not at the same starting place. The non-athlete may have had a Z-score of 0, while the athlete has a starting Z-score of +1.
And what this means is it’s the athlete, not the non-athlete, that’s had a higher degree of degradation in bone density.
Unfortunately, it’s rare to have this earlier DEXA scan to compare to because it’s usually not done unless a problem is suspected. And so rather than having a comparison, you are simply looking at today’s result.
So if someone is an athlete, because of how this can impact the results, it needs to be factored in, otherwise, a timely intervention can easily be missed.
Given how many of the clients I work with have exercised to a high degree (and are often continuing to do so) this is incredibly relevant. And it was one of the things I learned from Dr Gaudiani’s book that has been most useful.
Exercise is incredibly important for bone health. Moving our body and therefore applying force on the bones leads to thicker and stronger bones.
Astronauts are the perfect example of what happens when this force is missing. In a matter of weeks in zero gravity, they can lose up to 10% of their bone. This is why, for astronauts on the International Space Station who will be away in space for many months at a time, they’ll spend 2-3 hours a day exercising to try to mitigate the damage to bones (and muscle).
Because so many of my clients have received a diagnosis of osteoporosis or osteopenia, they often believe they should continue exercising. Or more correctly, the eating disorder is adamant that they should keep exercising. Often believing this is still true even while they have a stress fracture.
So what’s best for bones? Should you be exercising in recovery?
Healthy bone is not solely down to exercise. It is exercise plus adequate calories/nutrition, adequate hormones and adequate rest. Without those other factors, exercise doesn’t improve bone health. It’s not even neutral; it actually leads to worse bone health.
And exercise in this context isn’t just going for a run, a cycle or lifting weights. Exercise can also include restlessly and incessantly walking around or lots of time spent cleaning. Much of the low-level movement that can fly under the radar of being considered “exercise” actually should be thought of as exercise.
So, even though we are all told to exercise to improve bone health, this is just one part of it. When in a nutritionally sound place, with well-functioning hormones and the ability to sleep well and get proper downtime, this is the time when exercise truly supports bone health. But without this happening, it’s not.
I started this article by making reference to the rather grim statistic that many people die within a year of having a hip fracture. With the causes of death, some of the reasons feel connected to the injury itself: pulmonary embolism, infection and heart failure. Others are diseases that we may associate with being older: dementia and Alzheimer’s disease.
But given the clients I work with and my understanding of how bone health is tied to the health of other systems of the body, I think there is more to this than simply old age and the unfortunate knock-on effect of sustaining a hip injury.
In many ways, bone health can be seen as a proxy for overall health.
Sure, we all have genetic strengths and weaknesses. Someone can live with an eating disorder for decades and yet have very good bone health. While someone else can live a healthy life and simply have more fragile bones.
But outside of these outliers, bone health is typically in line with the health of other systems. As I cover in this article on HA when the body is not getting adequate energy, it also affects: hormones, metabolism, the blood, cardiovascular system, brain function and psychology, digestion, and immune function.
So, a poor score on a DEXA scan is more than just about bones, it’s typically an indicator of the state the body is in as a whole.
Have you received a diagnosis of osteoporosis or osteopenia? Do you have a recurrent stress fracture or have you recently broken a bone? Do you have a history of or are you currently trying to recover from disordered eating or an eating disorder?
If so, I would love to help.
I have worked with many clients to reverse the damage that their bones have experienced. While completely repairing this situation is nearly impossible, for reasons I have outlined in this article, I have seen dramatic improvements.
Going from a diagnosis of osteoporosis to now being back in the normal category.
Or struggling with pain and fractures that never seem to repair to reaching a place of feeling healed. So much so that they have returned to regular exercise or movement, feeling stronger than in years (or decades).
I’m a leading expert and advocate for full recovery. I’ve been working with clients for over 15 years and understand what needs to happen to recover.
I truly believe that you can reach a place where the eating disorder is a thing of the past and I want to help you get there. If you want to fully recover and drastically increase the quality of your life, I’d love to help.
Want to get a FREE online course created specifically for those wanting full recovery? Discover the first 5 steps to take in your eating disorder recovery. This course shows you how to take action and the exact step-by-step process. To get instant access, click the button below.
I wish you (and your bones) all the best.
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